00030125 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q 'O J Z ``.+
CITY OF CUPERTINO BUILDING-ELECTRICAL PIiRh1FT NO
BUILDING DIVISION APPLICATION/PF.RMIT PLfIM1101NG-MECHANICAL S0001
BUILDING PROJECT IDEN'1'Imml-08
SANITARY NO, APPL1'ATION SUBMI'1'IAI.DAT
IRU I LIII NO ADDRCSS:
02131 I IV1 1 vrc�
OWNF.H:SNAMtitw _ � �- CONTRACfOR'$NAMI!: LIC NO: NIC CONTROL#
.iCHI'I'IiCT/ENGINEF,R: LIC NO: ADDRESS: ❑
J BUILDING PERMIT INFO
CONTACC PHONE:
/ �WJ�r� JOwUr 7 0
5I0 ❑ CoCUOSlIJN PCCPall by Applicant(IDIrIllI) BLDG ELECT PLUMB
MECH
❑ 2- IY 2--�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE JOB DESCRIPTION
I hereby effnd that I am licensed under provisions of Chapter 9(commencing
mcc2 wish Sectinn'll00)atDh;doo3efine 1hromssand Prnfesxi+m.Cadaaad my hearse is RESIDENTIAL
F C
in forte and effect. PERMIT ISSUANCE ❑SI'DWI. ❑KITCHEN REMODEL
CSF m
Qb+V[, laccnsc Clax Lic.b _ APPLIANCES-RIiS1UENTIAL ❑ADDITION (:1 PLUMBING URAL N Q L Uutc Con¢u- I
AHCHTTECI'S DECLARATION PANEIS ❑M11ULI'1-11X1"f ❑MODIFICATIO
F m Z 1 understand my plain shall be used as public records MODIFICATION
OZHQ UVT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
F-1FW Licam al Protest ml 201-1000AMPS IMPROVEMENT [DSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER land AMPS ❑BATH REM aLIREPAIR ODEMOLI PION
C C Q 1 hereby affirm that 1 am exempt from the Conmamrs License Law for the fTfHER
x�x C L U following lassoo(Section 911715.Business anti Prefo_nslo o,Ca&Any city or county SIGNS ELECTRICAL
W 3 e yQ which requires a pereau r+comuua.alter,improve.eemelieb,er rapid,any smrembe CIA 0
�,LLCJ
prior to its ., n e Iso haplims the applicantf ch pennit tofile a signod'emembent SPECIAL CIRCUITIM ISC.
�} her lie Ipursuant t th P m,n ftl C Ir I,rxL L (Chapter I I'
hC (commencing withSection 1010)ofDivisions oftb Business ad professionsCtde)nr '1I:MP.MI!'I}R OR POLE INS'I'.
6 c X that he is exempt tharefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION [I DEh101.1'I'ION
6
X=u Section 9071,5 bytmy applicant fora permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TIiNAN'1 ❑FOOD SERVICE
w' not mor a than live hundred doll...($500),
IMPROVEMENT
FL �I oche work,the propeustructure myot intended wiNwagcs r ileirarde e0mpenanan. SWLMMIN(i I'OOh IiLECI'RIC ❑OTHER ,
W p=.0 will datncsiuns Coil::and OCtmdiuciol intended dJsnorapply to an.Business
L 3 m and Pndwho h ilds o:Tnc Catnnmtreon License w Law Joe not apply to if nlhra er OUTL[!TS-SWITCIiES-PI%TURES
his own who builds or improves thereon,and who aces such work deed m m Ned for
his own empl%hes,prm'idcJ that su[h improvements tee not intended or nRemd for NEW RI5IDENTIAI.ELECTS SQ P T. )R AREA SISQ,Fi
ode.If,however.the building or improvement is slid within one year of Completion,the
tavrscr.builmu will have the burden of proving that he did not build or improve till Pur-
pom of sole.). TOTAL:
I,as owner of the property am exclusively contracting with licensed contractors to
mnsunet the project(Sec.ass,Business and Pofiessh's Comm)Tim Comrmu+r's Li-
:e Lewdaesnot apply n+an owner of propery who buildso,Impm.es Bmreon,and QTY. PLUMBING PERMIT FEE
who antras,for such pnjects with a coloom or(s)licensed parsunnran the Comracher's
Liana Law. PERMIT ISSUANCE
I all,exempt under Sec. .B&P C for lois m.oun
ALTER-DRAIN&VENT-WATER U[A) VALUATION
Owner Data 'l
WORKERI COMPENSATION DECLARATION HACK FLOW PROTECT DEVICE V
1 hereby dEml under Penalty offsequry one of the following declarations
❑I have and will maintain a Certificate ofConsen to self-insure for Worker's Compere DRAINS-FLOOR.ROOF.ANr .CONU. STORIES TYPE CONSTRUCTIO
tion,t s pnrvidnI ter by Section 7]1X1 of the Fa bah Core,fill the perforeamcc of Inc
which t's Pem+it in issued. i'I%TURES-PER'TRAP
wor have and will maintain Worlees Compensation Inurenee,a%myuited by Section .
7910 of the Labor Ce.for the performance of the work for which this pem+it is issued. GAS-EA.SYSTEM-I INCi OUTFITS OCC.GROUT' AI'N
My WorkeJ{}t..�Q n��ffRR��++IptJJ yy�� 'r and Policy number e9/__
Cartier" IGritLl"rt"'ah6aJ'TTy$'Yoli[y No
GAS-EA.SYSIPM"OVER4(EA) LC. " 1
CERTIFICATE OF IIXEMPI'[ON FROM WORKERS' GREASIVINDUS1'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FRES
(hhsction need not be completestribe Permit is fince,hundred dollars($100) GREASE TRAP PLANCHECK FEE
or Iona.)
Ircnifymar in thearmfo..Ile' o 'ofthe
workII
which this theta is kes, d.Ishrll SF,WER-SANITARY-STORM BA.210 FT. ENERGY FIiIi
no,cn+piny any person army moaner m,us m hccanw.eunjmne Nc Wnrkcrn'Compere
Z ration loss of California.Date WATER HEATER wNF'.YTtiLECTR GRAVING PEE EEE
zZ Applicant t
h NOI ICE 10 APPLICANT'.ll:ager making this Ccnilicntc of lixemptinn,you should WAI ER SYSTEM/TREATING SOILS FEE
became mbjea ,the Workers Cmnpensation provision of the Lothar Code,you mint
forhwith comply with such Provisions or his permit shall be deemed revoked. WATER SERVICE
7
CONSTRUC'T'ION LENDING AGENCY NEW RESIUIiN1'IALI'LMB, SQ.FT. PAID
U Uwc Rcuuipt p
U 0 Iherehy affirm that isaconswminn lending agexy for the Perfam+an<e of
"I the work for which this permit is ismcd her.7099,Civ.C.) TOTAL:
O U Leaders Name 'HYI'AU
,r Londe/x Address BUILDING FEE
1 verify that 1 have mai this application and state that the above information is
Tai)
correct.I agree m comply with tdl city and county ordinarce.,and mac mwx relating n+ QTY. MECHANICAL PERMIT FEE SEISMIC peE
U rZ building construction.and hereby aulhoriee replesealr Ives ofthis city laemer upon Ile
abovcmentioned property for inspection putpoma" PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hanat the City of Cuperino against
liabilitics,judgmm�m ms and expenses which may many way uccmc against said City ALTER OR ADD'1'0 MECH PLUMBING FEE
in cenmque Col th mmin6""his permit.
APPLICA - UND RSTANDS AND WILL COMPLY WITII .L N)N-POINT ATR HANDLING UNIT(10 10.000 CFM) MECHANICAL FEE
SOLI "r :GUL 1 ONS,
AIR HANDLING UNIT(OVER If1.I1fN)CPM) CUNSTRUCfION'TAX
St nature fAPPlican actor —as EXHAUST HOLD DYMUCD HOUSINGMFTIGATIONFLE
A' RDOUSMATERIALSDISCLOSUIR
Willrhea licunt r future Wilding oecupaat more or handle harardous material HEAPING UNIT(TO 00,000 BTU)
as defined ny the Cupero o stone I Ctde.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10.000 BTU)
Code,Section 25532(n)'? ,J/pa
❑Yes YJ tuft VENTILATION PAN(SINGLE RCSID) PAID
Dam Receipt p
Will the applicant or future building occupant use eyuipmem nr devices which BOILI?R-COMP
epI1P OR 100.0g)BTU)
mit by dous air cmenoinanls load by the tiny Area Air Quality
as yCManagementTOT' T
Dimfictn. .V,`/`/ BOILER-COMPIOVER TW.00B1U)
Ycs
AIR CONDITIONER ISSUANCE Tim I;
1 na read NC havmdoas nmterials regairemema ander anopia,e.95 or Ne emi-
himia Heeu &Safety Code.Sections 25505.25577 and 2557x.1 undersand Nat if the NI?W RESIDENTIAL MECH. SQ.FT.
building bol centrally have�a�++cmm.II,a itis my resrytmihi lity s.notifyhcce,upant
oft wi nor be tncl priorIII iawanis cc ora CeM1 it te,'lcu ry.
1 /, TOTAL: ISSUED BY:
Ow eJ 6cm
OFFICE